Retinopathy of Prematurity (ROP): Standards, Screening, and Litigation

Development of Retinal Vessels in Retinopathy of Prematurity

Retinopathy of prematurity remains one of the most significant and preventable causes of childhood blindness worldwide. In the UK, ROP litigation arises when screening opportunities are missed, follow-up is delayed, or treatment thresholds are misunderstood. Because ROP develops rapidly and may progress to retinal detachment in a matter of days, the medico-legal scrutiny is intense,

and the required standard of care is high.

This blog is written for medical professionals, expert witnesses, and all stakeholders involved in neonatal and paediatric care. It clarifies the clinical, legal, and evidential expectations surrounding ROP screening and management.

1. Why Retinopathy of Prematurity (ROP) Matters in Medicolegal Practice

ROP combines three characteristics that make it a frequent source of claims:

• high vulnerability of premature infants

• rapid disease course requiring timely detection

• clear UK national guidelines outlining responsibilities

When standards deviate, irreversible blindness or severe visual impairment may result. Expert witnesses are often asked to analyse whether these outcomes were avoidable.

2. Who Should Be Screened: Understanding the Criteria

UK guidelines specify which infants require ROP screening. Screening is mandatory for:

• babies born at less than 32 weeks gestation

• babies with a birth weight below 1501 grams

Medical professionals and expert witnesses must recognise that failure to identify eligible infants is a breach of duty in itself. Courts view this as a systems failure, not a clinical oversight.

3. Timing of Screening: The Most Common Source of Negligence

ROP screening is time critical. Examinations must be performed:

• by 31 weeks post-menstrual age, or

• by four weeks chronological age

whichever is later.

Claims frequently arise when:

• the first examination occurs too late

• babies are transferred between units without clear handover

• screening is overlooked during neonatal instability or transport

• documentation is incomplete

The law expects neonatal and ophthalmology teams to ensure screening is not missed, regardless of logistical pressure.

4. Recording Findings: Documentation Is Often the Deciding Factor

The ROP examination is not simply a clinical procedure. It is a medico-legal record of the infant’s retinal status at a specific moment in time.

Documentation should include:

• zone of vascularisation

• stage of any ROP

• presence of plus disease

• clock hours involved

• clarity of view

• planned follow up interval

When documentation is sparse, courts often infer substandard examination or inadequate assessment.

5. Follow Up and Interval Breach

ROP may progress rapidly. Poor scheduling or overly long intervals constitute breach when:

• infants are reviewed later than guideline timeframes

• follow up does not match disease severity

• discharge occurs before retinal vascularisation is complete

• communication between teams is unclear

Expert witnesses must determine whether the follow up plan matched accepted practice at the time.

6. Treatment Thresholds: When Delay Becomes Causative

Timely treatment is essential. Based on ETROP recommendations, treatment should occur for:

• Type 1 ROP

• Zone 1 disease with plus

• Posterior Zone 2 Stage 3 with plus

• Aggressive posterior ROP

Delays in initiating laser or anti VEGF treatment remain one of the most litigated aspects of ROP care.

The expert must evaluate:

• when treatment should have occurred

• whether the disease had already progressed to an irreversible stage

• whether earlier intervention would likely have changed the visual outcome

Causation analysis is central. The question is not whether blindness occurred, but whether it was preventable.

7. Transfer of Care: A Critical System Vulnerability

Many ROP claims arise from failures during transfers between:

• NICUs

• Special care baby units

• Community follow up pathways

• Hospitals across regions

At each transfer, responsibility for screening must be explicitly handed over.Experts often identify that screening was “assumed” to have occurred, resulting in missed examinations.

This is a system level breach, not a clinician level failure.

8. Discharge Without Full Vascularisation: An Avoidable Risk

Discharging infants before the retina is fully vascularised is unsafe unless a robust outpatient follow up plan is guaranteed.

Negligence may arise when:

• no discharge plan is recorded

• community teams are not informed

• parents are unaware of the importance of follow up

• follow up appointments are not scheduled before discharge

Expert witnesses should consider whether earlier completion of vascularisation or timely follow up would have prevented progression to sight threatening disease.

9. Long-term Impact: What Experts Must Explain to the Court

ROP does not end with early treatment. Children may later develop:

• high myopia

• strabismus

• glaucoma

• retinal detachment

• reduced acuity

• social and educational difficulties

The expert’s report must articulate:

• the visual prognosis

• the functional implications

• whether harm was avoidable

• whether disability is permanent

• whether secondary complications were predictable

Courts rely on this clarity when assessing quantum and long-term care needs.

Conclusion

ROP litigation concentrates on three fundamental pillars:timely screening, appropriate follow up, and urgent treatment when indicated.

Medical professionals and expert witnesses must understand not only the clinical pathway but also the legal expectations that govern ROP care. Accurate documentation, stable systems, and timely recognition of disease progression remain essential safeguards.

For the court, the ophthalmic expert provides the scientific framework needed to determine whether harm was preventable. When carried out with precision, neutrality, and insight, ROP expert evidence becomes a decisive component of justice for premature infants.